Early Puerperium Research Articles

Miocardiopatía periparto como causa de insuficiencia cardíaca durante la gestación

Peripartum cardiomyopathy is a rare form of heart failure that affects women late in pregnancy or in the puerperium, with potentially fatal consequences. The clinical presentation is the same as in congestive heart failure, and sometimes the diagnosis is overlooked due to the occurrence of similar symptoms, such as dyspnea, during normal pregnancy. The treatment is similar to that for other types of left ventricular dysfunction. However, modifications to standard treatment are sometimes required for the safety of the mother and fetus. With few exceptions, vaginal delivery with a facilitated second stage with forceps is preferred in women with heart disease. Hemodynamic control of the patient during the early puerperium is highly important. Mortality estimates range from 30-40%; most deaths occur within the first three months postpartum, although 50% of patients show marked improvement in ventricular function.

Von Willebrand factor-cleaving protease (ADAMTS13) activity in normal non-pregnant women, pregnant and post-delivery women

ADAMTS13 dysfunction has been involved in the pathogenesis of Thrombotic Thrombocytopenic Purpura. This disorder occurs more frequently in women and, in 13% of them, is associated with pregnancy. However, there is little information on the protease behaviour in normal pregnancy. We studied von Willebrand factor and ADAMTS13 activity changes in normal non-pregnant, pregnant and post-delivery women. Fifty-five non-pregnant women, normal blood bank donors, who were not taking contraceptive pills were included as controls. A prospective cross-sectional study of 270 normal pregnant and post-delivery women was carried out. ADAMTS13 activity decreased progressively as from the period of 12-16 weeks up to the end of early puerperium (mean 52%, range 22-89, p < 0.0001), to increase slightly thereafter. Nulliparous presented mildly lower levels of ADAMTS13 activity than parous women (65% vs. 83 %, p = 0.0003), and primigravidae than multigravidae between 6-11 weeks up to 17-23 weeks of pregnancy (69% vs. 80%, p = 0.005). Although in all women the protease levels were the same by blood groups, the O blood group non-pregnant women showed a higher mean of ADAMTS13 activity than those non-O (78% vs. 69%, p = 0.064). Our results suggest that the changing levels of protease activity during pregnancy and puerperium, induced by unidentified mechanisms, could render the peripartum time more vulnerable to developed thrombotic microangiopathies.

Sangrado transvaginal durante el embarazo, como factor de riesgo para isoinmunización al antígeno Rhesus-D

The aim of the present study was to evaluate transvaginal bleeding (TVB) as a risk factor for Rhesus isoimmunization during pregnancy, in order to optimize the application of Anti-D gammaglobulin in non-immunized pregnant women, as an alternative to the routine application of Anti-D at 28 weeks of gestation. This case-control study was conducted from 1995 to 2001 at Mexico's National Perinatology Institute. Cases (n = 24) were non-immunized pregnant women who showed positive anti-D antibody seroconversion during pregnancy or during the early puerperium. Controls (n = 24) were non-immunized pregnant women who enrolled after each case, with similar clinical characteristics but who had no anti-D antibody seroconversion during pregnancy. In all cases the newborns were Rh-positive. None of the patients received immunoprophylaxis at 28 weeks of gestation. The presence of TVB was recorded at any stage of pregnancy and before labor. Odds ratios with 95% confidence intervals were used to assess associations. TVB was observed in 18/24 (75%) cases and in 5/24 (20%) controls. Preterm uterine contractions and threatened miscarriage were the most frequent causes of TVB. The presence of one TVB event during pregnancy increased 11.4 times (95% CI 2.9-44.0) the likelihood of Rhesus isoimmunization. TVB after 20 weeks of gestation increased the likelihood 5.0 times (95% CI 1.3-19.1). TVB before 20 weeks of gestation was not significantly associated with Rh isoimmunization (OR = 7.6, 95% CI 0.8-69.5). Prophylaxis with anti-D gammaglobulin should be given to all non-immunized Rhesus-negative pregnant woman with TVB at any stage of pregnancy. The English version of this paper is available at:http://www.insp.mx/salud/index.html.

Depression in the early postpartum period and attachment to children—in mothers of NICU infants

AbstractDepression in early puerperium was evaluated in terms of maternal attachment in mothers of children admitted to the neonatal intensive care unit (NICU) in comparison to a control group of mothers of full‐term infants.A survey including Zung's self‐rating depression scale (ZSDS), a postpartum maternal attachment scale and items addressing the mother's feelings and peripheral conditions was conducted on mothers of children admitted to the NICU.Among the 153 mothers who gave valid responses, positive ZSDS scores of over 40 were seen in 61.8%. In terms of the children's disorder, strong depressive tendency was noted among mothers of low birth weight infants. Significant correlation was noted between the ZSDS and the ‘core maternal attachment’ (negative correlation) and ‘anxiety regarding children’ (positive correlation) subscales of postpartum maternal attachment. Path analysis revealed the father's positive reaction in learning of the pregnancy resulted in elevation of the ‘core maternal attachment’ score, in contrast to the control group mothers. Copyright © 2003 John Wiley &amp; Sons, Ltd.

Cervimetry and ultrasonographic observations of the cervix regression in dairy cows during the first 10 days post partum.

The aim of this study was to describe the involution process of the bovine cervix during the first 10 days post partum by using an intracervically introduced gauge and transrectal ultrasonography. Twenty-five pluriparous Holstein Friesian cows were included, which were randomized into three groups: group 1 (n = 10): transrectal ultrasonographic presentation of the formation of cervical folds; group 2 (n = 10): measurement of the reduction of the canalis cervicalis using an intracervically introduced gauge. The examinations were performed directly after expulsion and 2, 4, 6, 8, 12, 16, 18 and 24 h post partum, and in intervals of 24 h up to the tenth day. The involution process can be divided into four phases: 1: fast reduction up to the sixth hour; 2: protracted reduction up to the second day without constant formation of folds; 3: protracted reduction up to the seventh day with constant formation of folds; 4: re-opening of the canalis cervicalis maintaining the structure of the folds. The reduction process (phase 1- phase 3) can be shown as the sum of two exponential functions with different grading coefficients: y = reduction 1 x e(-b1 x t) + reduction 2 x e(-b2 x t). Reduction 1 is reduction in cm during the first phase and reduction 2 is reduction in cm during the second and the third phase. Group 3 (n = 5): to exclude an influence of the high frequency of examinations on the involution process the cows were examined immediately after parturition and on the fifth and tenth day postpartum using the same method as in groups 1 and 2. In conclusion, the involution process of the bovine cervix guarantees a fast protection of the cavum uteri and a drainage of the lochia at the end of the early puerperium. The re-opening phase after the seventh day has not yet been described in any other species and can be interpreted as the adaptation to the exsudative puerperium in the cow.

Factor VIII and von Willebrand factor changes during normal pregnancy and puerperium.

Gestation is a challenge to haemostasis and it is associated with significant haemostatic changes. Several studies have evaluated von Willebrand factor in normal pregnancy, but none considered the personal history of bleeding. We studied a group of healthy non-bleeding women (184 pregnant, 64 puerperium, 37 non-pregnant) to evaluate normal ranges and their relationship to blood group and parity. The von Willebrand factor increased markedly from non-pregnant values up to the end of early puerperium (P < 0.0001), while factor VIII only showed a slight increase. Factor VIII and von Willebrand factor activity remained within the normal range for non-pregnant women. The return to non-pregnant factor levels occurred in late puerperium, later than previously reported. Only factor VIII was significantly lower in the O blood group (P = 0.035). As regards parity, there were no differences in factor VIII, von Willebrand factor antigen and von Willebrand factor ristocetin cofactor between primigravidae and multigravidae for any period studied (P = 0.888, 0.999, and 0.237, respectively). Our results provide reference ranges that may help to design a study in von Willebrand factor disease in pregnancy.

Mood disturbance in the early puerperium: a review.

This paper reviews the range of symptoms, timing and measurement of mood disturbance in the early puerperium. The prevalence and risk factors for postpartum blues and elation are discussed. The most convincing relationships are between blues and dysphoria during pregnancy, a past history of depression, neuroticism and premenstrual depression. Biological research is inconclusive. Blues and elation are predictors of subsequent postpartum depression and appear to be an index of affective vulnerability.

Maternity blues:cross-cultural variations andemotional changes

The maternity blues are a group of symptoms of overemotionalism and overreactivity that appear very often in the early puerperium. The blues seem not to be part of a continuum with postpartum depression and puerperal psychosis. Causation is mostly biological, mainly the massive fluctuation of hormones in that period. There are no clear relationships with demographic or psychosocial factors. The clinical picture appears very similar in all the different settings in which it has been examined. As some women suffering from the blues will go on to develop postpartum depression, requiring medication and psychological interventions, it is very important to recognize the symptoms and to educate the patient and her partner, if there is one, so they will know what to expect and when to notify the obstetrician/gynecologist in case psychiatric referral is necessary. The time spent listening to the patient discuss her emotions and giving her pertinent education is very valuable, because the establishment of a good therapeutic alliance is crucial in the event that depression (a serious condition that puts both mother and child at risk) develops.

Fatty acid composition of phospholipids and cholesteryl esters in maternal serum in the early puerperium

The fatty acid composition of serum phospholipids (PL) and cholesteryl esters (CE) in 26 healthy pregnant women at the end of term and 1 and 3 days after delivery was analysed in order to determine whether the maternal serum fatty acid composition changes in the early puerperium. The composition of the saturated fatty acids significantly changes in the PL fraction: 16:0 decreased and 18:0 increased. Both 20:4n-6 and 20:5n-3 significantly increased after parturition in serum PL while 22:6n-3 remained constant at the three sampling time points. The sum of HUFA was slightly higher 3 days postpartum compared to the prepartum data. The essential fatty acid index significantly increased after delivery. In the CE fraction too differences occurred during puerperium: 18:2n-6 and 20:4n-6 increased and 18:1n-9 decreased after parturition. The sum of the n-3 fatty acids in CE remained unaltered. The EFA index significantly improved both in PL as in CE after delivery. In conclusion, the previously reported changes in the fatty acid composition of PL and CE during normal pregnancy diminish shortly after delivery. In fact, very soon after delivery the maternal fatty acid composition returns to more normal values.

Die Geburtserfahrung - eine Übersichtsarbeit

The last two decades have seen an increasing interest in research in the area of birth experiences. The research has focussed on four areas with regard to their influence on the birth experience. These areas included obstetric and analgesic variables, relational parameters, prenatal development and intrapartum subjective experience. Birth experience is generally ascertained in the early puerperium with regard to an overall satisfaction score. Bias is due to various situational factors. Problems in satisfaction research arise from the fact that birth experience cannot be assessed through one single item. We suggest to analyse birth experience already during labour and therefore try to contribute towards a dynamic approach to well-being in birthing.

Herpes gestationis may present itself as a paraneoplastic syndrome of choriocarcinoma—a case report

Background Herpes gestationis (HG) is a rare, recurrent, pruritic, vesicobullous dermatosis occurring predominantly in pregnancy and seldom in early puerperium. Reports of the association of HG with choriocarcinoma are extremely rare and this case highlights such a possible link. Case This case focuses on the late postpartal manifestation of HG being associated with metastatic high-risk choriocarcinoma. Direct immunofluorescence was used to verify the diagnosis of HG. Symptomatic therapy with corticosteroids and antihistamines alleviated the pruritic symptoms associated with HG, but only the recurrent course of chemotherapy for the choriocarcinoma resulted in complete disappearance of all signs and symptoms of the HG. Conclusion The time course of this case highlights once again the possible association of HG as a paraneoplastic syndrome of choriocarcinoma.

Anomalías hemodinámicas cerebrales en gestantes con preeclampsia

Transcranial Doppler (TCD) is being used more and more frequently in the study of brain haemodynamics in pre-eclampsia/eclampsia. It has received less attention in the puerperium of these patients. The aim of our study was to compare pre-eclamptic (PE) and normotensive (NT) patients at the end of gestation, using a Doppler velocimeter, and also to compare the results from PE women in two consecutive periods of time: at the end of gestation and in early puerperium (EP). TCD was performed with bilateral evaluation of the anterior, middle and posterior cerebral arteries (ACA, MCA and PCA, respectively). Average speed (AS) and the pulsatility index (PI) were used as Doppler parameters. Arterial blood pressure (BP) and haematocrit were also measured. The AS, PI, average BP (ABP) and haematocrit were used as variables in the statistical analysis. At the end of gestation (33 weeks to full term) we compared the average values of these variables in PE (n=38) against those of NT (n=44). We also compared the results obtained for PE (n=30) in two consecutive periods: at the end of gestation and EP (the first five days following childbirth). At the end of gestation, AS were significantly higher in the PE than in the NT in all the arteries that were examined. The ABP was higher in the first group but there was no significant correlation between ABP and AS. PI were lower in the first group, with statistical signification in four of the six arteries. The AS rose significantly in the EP of the PE women, in spite of the existence of a drop in the ABP. Conversely, the PI remained unaltered. A pattern of high AS and low PI was found in PE women at the end of gestation and may be due to a primary failure of the brain's capacity to regulate itself. Anomalies in the TCD increased in the EP, despite a drop in the ABP, and this could account for the predominance of the neurological symptoms that are reported in the later forms of the syndrome.

Depressive and anxiety symptoms in the early puerperium are related to increased degradation of tryptophan into kynurenine, a phenomenon which is related to immune activation

There is now some evidence that i) the availability of plasma tryptophan, the precursor of serotonin, is significantly lower in pregnant women at the end of term and the first few days after delivery than in nonpregnant women; and ii) both pregnancy and the early puerperium are accompanied by activation of the inflammatory response system. The aims of the present study were to examine the effects of pregnancy and delivery on plasma kynurenine, a major tryptophan catabolite synthesized after induction of indoleamine-2, 3 dioxygenase (IDO) by pro-inflammatory cytokines. We measured plasma kynurenine and tryptophan and immune markers, such as serum interleukin-6 (IL-6), IL-8 and the leukemia inhibitory factor–receptor (LIF-R) in healthy, nonpregnant and pregnant women at the end of term and one and three days after delivery. Plasma kynurenine was significantly lower in pregnant women at the end of term than in nonpregnant women, findings which may be attributed to lower plasma tryptophan at the end of term. The kynurenine/tryptophan (K/T) quotient was significantly higher in the pregnant women at the end of term and in the early puerperium than in nonpregnant women. In the early puerperium there was a significant increase in plasma kynurenine and the K/T quotient. The increases in plasma kynurenine and the K/T quotient were significantly more pronounced in women whose anxiety and depression scores significantly increased in the puerperium. The changes from the end of term to the early puerperium in plasma kynurenine and the K/T quotient were significantly related to those in the immune markers. It is concluded that 1) lower plasma kynurenine at the end of term is the consequence of lower plasma tryptophan; 2) the increased K/T quotient at the end of term and in the early puerperium indicates inflammation-induced degradation of tryptophan along the kynurenine pathway; and 3) that depressive and anxiety symptoms in the early puerperium are (causally) related to an increased catabolism of tryptophan into kynurenine, a phenomenon which probably results from immune activation.

Sonographic visualization of ovarian veins during the puerperium: An assessment of efficacy

Objective: The purpose of this study was to determine the ability to visualize ovarian veins by sonography in postpartum patients as well as to assess the frequency of ovarian vein thrombosis in these patients. Study Design: Seventy subjects were recruited from either the postpartum ward or labor and delivery unit after vaginal delivery between November 1, 2000, and March 1, 2001. Patients were excluded if they had a previous or current history of venous thrombosis or recently underwent cesarean delivery. Demographic data were recorded. Transabdominal ultrasonography was performed with gray scale or color Doppler imaging for visualization of the right and left ovarian veins. Either power Doppler or pulsed Doppler imaging with spectral analysis was used for verification of the ovarian veins. Logistic regression was used for univariate analysis. Results: Of the 70 parturients studied, both ovarian veins were visualized in 55 women (78.6%). Of the remaining subjects, either the right (n = 6) or the left (n = 6) ovarian vein could not be visualized. In 3 subjects, neither ovarian vein could be visualized (4.3%). An isolated, asymptomatic right ovarian vein thrombus was identified in one subject (1/55, 1.8%) after bilateral tubal ligation was performed. Maternal age, parity, body mass index, gestational age, spontaneous versus operative vaginal delivery, neonatal sex, or sonographer (radiologist versus perinatologist) did not correlate with ability to visualize the ovarian veins; however, increasing birth weight tended positively toward significance (P =.064). Conclusion: Most ovarian veins can be visualized sonographically during the early puerperium. Additional imaging studies should be considered when a diagnosis is unclear. The presence of an asymptomatic ovarian vein thrombus is unusual and is of uncertain importance. (Am J Obstet Gynecol 2002;186:893-5.)

Clinical predictors for a high risk for the development of diabetes mellitus in the early puerperium in women with recent gestational diabetes mellitus

Objective: The purpose of this study was to identify which maternal, antepartum, or neonatal clinical parameters were predictive for a high risk of diabetes mellitus in the puerperium in women with recent gestational diabetes mellitus and to calculate the associated diabetes mellitus rates and odds ratios. Study design: One thousand six hundred thirty-six women underwent an oral glucose tolerance test within 1 to 4 months of delivery. Demographic, historic, and antenatal glycemic parameters and neonatal outcome parameters were tested by univariate and multivariate logistic regression for risk of postpartum diabetes mellitus. Continuous variables were divided into quartiles that compared the upper to lower quartile adjusted odds ratio and prevalence of diabetes mellitus. Results: Postpartum diabetes mellitus was diagnosed in 230 women (14.1%) according to the American Diabetes Association criteria (1997). No maternal demographic or neonatal parameters were significantly associated with diabetes mellitus. The final model of independent predictors in decreasing significance included the highest fasting plasma glucose level during pregnancy, any fasting plasma glucose level of ≥105 mg/dL (class A2), the area under the curve of pregnancy oral glucose tolerance test, gestational age at diagnosis, previous gestational diabetes mellitus history, and 50-g glucose challenge test results. The fasting plasma glucose level was the best discriminator, with a 21-fold (95% CI, 4.6-96.3) increased odds ratio comparing the 4th quartile (fasting plasma glucose level, >121 mg/dL; diabetes mellitus rate, 36.7%) to 1st quartile (fasting plasma glucose level, <95 mg/dL; diabetes mellitus rate, 0.5%). The presence of previous gestational diabetes mellitus or current class A2 gestational diabetes mellitus approximately doubled the odds ratio for diabetes mellitus. The odds ratio increased 3- to 4-fold when the area under the curve was ≥33.36 min · g/dL (4th quartile) or the glucose challenge test was ≥155 mg/dL (2nd–4th quartiles) and decreased >50% if gestational diabetes mellitus was diagnosed at >27 weeks (3rd-4th quartile). Conclusion: During pregnancy, the highest fasting glucose level, followed by the severity of glucose intolerance, and earlier gestational diabetes mellitus diagnosis were the best predictors for postpartum diabetes mellitus. Diabetic education should begin during pregnancy, especially for women who are identified to be at a high risk when they are highly motivated and under medical care. (Am J Obstet Gynecol 2002;186:751-6.)

Ultrasonic evaluation of the uterus and uterine cavity after normal, vaginal delivery.

To describe uterine and uterine cavity changes throughout the puerperium, as revealed by ultrasound. This was a prospective, longitudinal study in which 42 women with uncomplicated vaginal term deliveries were examined serially by ultrasound on postpartum days 1, 3, 7, 14, 28 and 56. The first four examinations were performed transabdominally and the last two transvaginally. The involution process of the uterus was assessed by measuring the anteroposterior diameter of the uterus and uterine cavity. Morphological findings were recorded. The influence on the involution process of parity, breast-feeding, maternal smoking and infant's birth weight were also evaluated. The maximum anteroposterior diameter of the uterus diminished substantially and progressively from 92.0 mm on day 1 postpartum to 38.9 mm on day 56. The maximum anteroposterior diameter of the uterine cavity diminished from 15.8 mm on day 1 to 4.0 mm on day 56. However, the anteroposterior diameter of the uterine cavity, 5 cm from the fundus, typically increased on days 7 and 14 postpartum. The position of the uterus and the shape and the appearance of the cavity change in a unique way during the normal puerperium. The uterus was most often retroverted and empty in the early puerperium. Fluid and debris in the whole cavity were seen in the middle part of the puerperium. In late puerperium the cavity was empty and appeared as a thin white line. Endometrial gas was occasionally visualized. No correlation was found between the involution of the uterus and parity, breast-feeding and the infant's birth weight. Transabdominal sonography is suitable for examination of the uterus during the first 14 days postpartum but from day 28 the transvaginal route is preferable. The uterine body and position, as well as the cavity, are easy to examine by ultrasound. Accumulation of fluid and debris in the uterine cavity is a common and insignificant finding of the involuting uterus. It is located in the cervical area in the early puerperium and in the whole uterine cavity in the middle part of the puerperium. Findings from uncomplicated vaginal deliveries are needed as a reference when the diagnostic efficacy of ultrasound for pathological conditions is to be tested.

Effects of pregnancy and delivery on the availability of plasma tryptophan to the brain: relationships to delivery-induced immune activation and early post-partum anxiety and depression.

There is now evidence that the availability of plasma tryptophan is decreased during pregnancy and the puerperium and also in patients with major depression and inflammation. The aims of the present study were to examine: (i) the effects of pregnancy and delivery on plasma tryptophan and the amino acids known to compete for the same cerebral uptake mechanism (CAAs), valine, leucine, tyrosine, phenylalanine and isoleucine; (ii) the relationships between the availability of plasma tryptophan and postpartum depression or anxiety; and (iii) the relationships between the availability of plasma tryptophan to the brain and inflammatory markers, such as serum interleukin-6 (IL-6), interleukin-1 receptor-antagonist (IL-1RA) and the leukaemia inhibitory factor receptor (LIF-R). The above variables were measured in 13 healthy non-pregnant and in 98 pregnant women 3 to 6 days before delivery and 1 and 3 days after delivery. On each occasion the parturient women completed the state version of Spielberger State-Trait Anxiety Inventory (STAI) and the Zung Depression Rating Scale (ZDS). Plasma tryptophan and the tryptophan/CAA ratio were significantly lower at the end of term and after delivery than in the plasma of non-pregnant, healthy women. The tryptophan/CAA ratio was significantly lower in the early puerperium than at the end of term. There were no significant relationships between the availability of plasma tryptophan and either post-partum depression or changes in the STAI or ZDS scores in the early puerperium. The changes in the tryptophan/CAA ratio from the end of term to the early puerperium were significantly and inversely related to serum IL-6, IL-IRA and LIF-R. The results show that the reduction in the availability of plasma tryptophan from the end of term to the early puerperium is related to immune activation; and that the lowered availability of plasma tryptophan is not related either to depressive or anxiety symptoms in the early puerperium or to post-partum depression ensuing some months later.

The inflammatory response following delivery is amplified in women who previously suffered from major depression, suggesting that major depression is accompanied by a sensitization of the inflammatory response system

Background: There is now evidence that some patients with major depression show an activation of the inflammatory response system (IRS). This study was carried out to examine whether major depression may induce sensitization with increased IRS responses to the stress of child birth. Methods: Serum concentrations of interleukin-6 (IL-6), the soluble IL-6 receptor (sIL-6R), sgp130 (the IL-6 signal transducing protein) and the sIL-1R antagonist (sIL-1RA) were determined in 16 and 50 women with and without a lifetime history of major depression, respectively. Blood was collected 3–6 days before delivery and 1 and 3 days after delivery. On each occasion the women completed the Zung Depression Rating Scale (ZDS). Results: Serum IL-6, sIL-6R, sIL-1RA were significantly higher 1 and 3 days after delivery than before. Women who had suffered from a lifetime history of major depression had greater increases in serum IL-6 and sIL-1RA in the early puerperium than women without a lifetime history. Women who had suffered from a lifetime history of major depression had significantly higher IL-6, and sIL-1RA concentrations 1 and 3 days after delivery than women with a negative life-time history. Conclusions: The responses of IL-6 and sIL-1RA following delivery are amplified in women who previously suffered from major depression. The results suggest that major depression is accompanied by a sensitization of the IRS.

Immunoreactive adrenomedullin (AM) concentration in maternal plasma during human pregnancy and AM expression in placenta.

Adrenomedullin (AM) is a novel vasorelaxant peptide, isolated from human pheochromocytoma. Although AM may be involved in the regulation of the cardiovascular system, a number of other mechanisms are also involved. The present study was undertaken to confirm the presence of AM in human maternal circulation and in placental function during pregnancy. Immunoreactive (ir) AM concentrations in maternal plasma were 3.4+/-0.7fmol/ml (mean+/-s.e. m.) in the first trimester, 3.3+/-1.1fmol/ml in the second trimester, 7.3+/-2.8fmol/ml in the third trimester, 4.1+/-1.9fmol/ml in early puerperium and 3.0+/-0.4fmol/ml in non-pregnant periods; the concentration in the third trimester was significantly greater than those in other periods. Plasma concentrations of estradiol (E(2)), progesterone, human placental lactogen (hPL) and human chorionic gonadotropin (hCG) were also measured, using RIA kits. Significant correlations have been demonstrated between the concentrations of irAM and those of E(2), progesterone and hPL. We therefore examined the expression of AM within the placental tissues using immunohistochemistry and northern blot analysis in order to demonstrate a correlation between the presence of AM in the placenta and maternal plasma. Using immunohistochemistry, we detected AM in the amnion at term and the expression of AM mRNA in human placental tissues using cloned human (h) AM complementary DNA as a probe. This study demonstrates the immunoreactivity of human hAM in maternal plasma during pregnancy, and suggests that hAM in maternal plasma is generated partly from placental tissue.

Effects of pregnancy and delivery on serum prolyl endopeptidase (PEP) activity: alterations in serum PEP are related to increased anxiety in the early puerperium and to postpartum depression

Background: There is now some evidence that anxiety or anxiety disorders are related to increased activity of serum prolyl endopeptidase (PEP) and that major depression is related to lower serum PEP. The aims of the present study were to examine (i) the effects of pregnancy and delivery on serum PEP and (ii) the relationships between serum PEP and postpartum depression, anxiety in the early puerperium and a past history of depression. Methods: Serum PEP activity was measured in 11 healthy nonpregnant and in 98 pregnant women 3 days before delivery and 1 and 3 days after delivery. On the same occasions, pregnant females completed the Spielberger State Anxiety Inventory (STAI) and were divided into high and low anxiety responders, as defined by changes in the STAI. The presence of a previous depression and postpartum depression within 3 months of delivery was assessed by means of DSM-IV criteria. Results: Serum PEP activity was significantly higher 1 and 3 days after delivery than before. Women with a past history of depression as well as anxiety responders had significantly increased serum PEP activity over nonpregnant women and puerperae with a negative history and anxiety nonresponders, respectively. Parturients who developed a postpartum major, but not minor, depression had significantly lower serum PEP than parturients without postpartum depression. The results were controlled for maternal and labor variables, such as type of analgesia and delivery, induction of labor, breast feeding, parity, and duration of pregnancy and labor. Conclusions: Our results show that, in puerperae, increased serum PEP is related to increased state anxiety in the early puerperium and that lowered serum PEP is related to a subsequent postpartum major depression. Interpretation: The results suggest that increased serum PEP may be related to postpartum anxious blues and that lowered serum PEP may predispose toward postpartum major depression.